CHAPTER XXI THE DIAGNOSIS OF DISEASES OF THE VULVA (Part 3)

to be found in the veins of the upper and inner thigh, and also in the vagina. Rupture of the veins of the vulva during delivery results in a hematoma of the vulva. 406 DISEASES OF THE VULVA VENEREAL LESIONS OF THE VULVA Venereal lesions include chancroids, chancre, mucous patches, and condylomata lata and acuminata. Chancroids are most often found on the fourchette, the inner surfaces of the labia majora, the nymphse, and the vestibule; they are multiple as a rule, and are more common among the uncleanly. Secondary infection is usual and fresh chancroids keep appearing; and often some that seem to be healed break down and ulcerate anew. The lesion begins as a pustule that soon becomes an ulcera- tion; the ulceration has a punched-out undermined edge, a soft, non-indurated base, which has a granular, uneven surface covered by a purulent discharge. This discharge is auto-inoculable. The sore is sensitive to touch. The chancroid appears about forty- eight hours after an infecting coitus and develops rapidly. Second- ary infection of the lymphatic glands of the groin (a bubo) involves commonly only one gland in a severe grade of inflamma- tion, causing pain and often suppuration. Chancre of the Vulva. — This is relatively rare, an extra-genital situation of the initial lesion of syphilis being more frequent in the female than in the male. Also, because of the inaccessibility of the parts and the trifling discomfort to which they commonly give rise, chancres of the vulva often escape observation. The initial lesion of syphilis, if situated on the vulva, is generally to be found on the labium majus; the next most frequent situation is the fourchette, then the nympha?, the clitoris, and the mons veneris in order of frequency. The chancre appears as a hard, red lump which soon ulcerates; the induration of its base being a characteristic feature, also the enlargement, in six to ten days after its appearance, of the individual lymphatic glands in most intimate connection with it. The chancre appears after an average period of twenty-six days from the time of inoculation, and is nearly always single, but may be multiple if several abrasions have been inoculated at the same time. The ulcer formed by the chancre has smooth edges, often elevated or sloping, never undermined, and the base is of smooth surface and indurated, and the secretion, which is serous and scanty, is not auto-inoculable. The infection of the lymphatic VENEREAL LESIONS OF THE VULVA 407 glands of the groins, primary adenopathy, affects several glands in a painless enlargement. Diagnosis of Chancre of the Vulva. — The diagnosis of chancre is often a matter of extreme difficulty. The discovery of the Spiro- chseta pallida in the secretions or a smear from the chancre makes the diagnosis sure, but failing this the three most important points are, the long period of incubation of the disease, the induration of the base of the sore, and the enlargement of the individual lym- phatic glands in the groin. A recent writer on the diagnostic significance of the spirochaeta pallida, R. P. Campbell, Jour. American Medical Association, Vol. LIV, March 19, 1910, page 924), speaks as follows from a large clinical experience in Montreal: "It should be possible to find the spirochaeta pallida in approximately 100 per cent of chancres ex- cluding those which are nearly healed, or have been actively treated, and some cases of mixed infection. In view of this fact, treatment should not be begun before the diagnosis is confirmed by finding the spirochete." Differential Diagnosis. — Herpes of the vulva is excluded by the appearance and the feel of the herpes: a superficial group of vesicles with a soft base disappearing after a short time. The crops of herpes may be multiple, while chancre is single. Furunculosis of the vulva has been mistaken for chancre. Here the boils are apt to be multiple and rim the usual course of a furuncle. The chief lesion that is confounded with chancre is the chancroid, and the distinguishing characteristics of the two lesions have been touched upon in the two preceding pages. Mucous Patches. — Mucous patches in the vulva are a frequent manifestation of secondary syphilis. They occur as moist papular syphilides and erosions, and have a discharge with a foul odor. The Spirochaeta pallida is abundant in scrapings from these patches and they are a most frequent source of syphilitic contagion. They are apt to be converted into condylomata lata or into a fusion of several papules to form cauliflower-like growths on the genitals, with fissures and ulcerations. Condylomata accuminata, occurring in cases of gonorrhea and unclean persons with irritating vaginal discharge, are not the same as the condylomata lata. The acum- inate variety are pointed, more wart-like, pedunculated, and of a branched, tree-like character. Their color may be that of the sur- 408 DISEASES OF THE VULVA rounding skin, or, if the epithelium has been removed by friction or maceration, they are of a deep red hue. They have a foul discharge and may affect any portion of the vulva or the inner surfaces of the thighs, and may grow to the size of a fist. Gumma. — A gumma as a manifestation of tertiary syphilis may develop as a round tumor in the labium majus. It has a tendency to break down by a sort of fatty degeneration, but not to suppurate. TUBERCULOSIS OF THE VULVA This is a rare affection, there being on record only some fifteen or twenty cases. The disease is generally seen in the ulcerative stage in women between twenty and forty years of age, the ulcers being of a grayish color, of varying size, with irregular edges, ex- hibiting in their bases tubercles in process of cheesy degeneration, and friable, poorly nourished granulations. The ulcers are situ- ated in the vestibule or on the labia or perineum. The diagnosis is often difficult, numerous sections of the ulcerated tissues being made before tubercles and the tubercle bacilli are found. The inguinal glands are not affected in this disease; the ulceration pro- ceeds slowly, having a course of from eight to ten years, and there is no marked induration of the tissues. The disease has been called also lupus vulvae, and esthiomene de la vulve. CYSTS OF BARTHOLIN'S GLAND It is not surprising that the duct of the vulvo- vaginal gland, which is only half a millimeter in diameter at its exit, should become occluded as a result of infective inflammation, thus damming up the secretions. Gonorrheal inflammation is supposed to be a cause for the obliteration of the duct of the canal and therefore a cause of the formation of a cyst. Be that as it may, cysts of Bar- tholin's gland arc of sufficiently common occurrence. They are usually unilateral, vary in size from half a centimeter to four centimeters in diameter, and occur during the childbearing period of life. The smaller ones may be due to the occlusion of a second- ary, branching duct, rather than the main duct. ABSCESS OF BARTHOLIN'S GLAND 409 A cyst gives little trouble as a rule, though the larger ones may interfere with coitus; they are rarely painful. The patient gen- erally gives a history of old inflammation of the vulva. The diagnosis consists in detecting a fluctuating, not tender swelling in the situation of the vulvovaginal gland (see figures from Huguier). Cysts of the secondary ducts and of the gland itself are situated Fig. 174.— Cyst of the Left Bartholin's Gland. (After Huguier.) deeper in the tissues and farther from the introitus vaginas than cysts of the main duct, and such cysts may be multilocular, where- as cysts of the main duct are always unilocular. When laid open cysts of Bartholin's gland are found to be filled with a glairy, colorless, white-of-egg mucus, and to be lined by a smooth mem- brane. ABSCESS OF BARTHOLIN'S GLAND Abscess of the vulvo- vaginal glands is very common and is due, in a large proportion of cases, to gonorrhea. One gland at a time is affected, as a rule, more often the left, and the disease is generally 410 DISEASES OF THE VULVA met with in women under thirty years of age, who are likely to have gonorrhea, such as prostitutes and women of loose habits. The duct of the gland, or the gland itself, may be involved, Huguier having reported cases of the former. (See Fig. 175.) In severe and neglected cases the gland becomes disorganized. Huguier thought that cysts of the duct or gland become infected and suppurate. Suppuration in the gland or canal is apt not to come on until the ■P V 1 ?fc\ 1 Obliterated excretory canaU / , Abscess of the 1 N m ffl| ; ^K duct Abscess of duct , J \ K6r/and laid opeq J' Fig. 175.— Abscess of the Ducts of Both Bartholin's Glands. (After Huguier.) later stages of gonococcus infection. Then there is a recurrence of heat and burning in the vulva with sharp pains, slight elevation of temperature, and tenderness of the tissues, the symptoms being aggravated by standing, walking, and sitting even, the patient being most comfortable in the recumbent posture. There may be retention of urine, or the urine simply smarts. Examination shows swelling and edema of the labium and sometimes pus escapes ABSCESS OF BARTHOLIN'S GLAND 411 from the orifice of the duct on the inner surface, or the abcess may be evacuated spontaneously through openings below the orifice. The inguinal lymphatic glands are affected sometimes and a " bubo " results. After the subsidence of the acute inflammation the vulvo- vaginal gland is apt to remain in a state of chronic inflammation and a drop of pus, perhaps with a greenish tinge, or a muco-puru- Fig. 176. — Abscess of Both Bartholin's Glands. (After Huguier.) A Drop of Pus is shown in the Orifice of Each Duct. Note Relation of Orifices to Introitus Vaginae. lent discharge issues from the duct. At this stage the orifice is surrounded by a red areola which resembles a flea bite, the so-called macula gonorrhoica of Sanger. It is in this stage that infection is apt to be transmitted to the male and light up in his urethra an acute gonorrhea, or it may cause puerperal sepsis or ophthalmia neonatorum. Relapse is common in abscess of Bartholin's gland 412 DISEASES OF THE VULVA and the opposite gland may become infected, therefore prompt surgical treatment is indicated. Smears should be made from the discharges and examined for the gonococcus. DIFFERENTIAL DIAGNOSIS OF CYSTS AND ABSCESS In cases of long-standing inflammation the tissues may be so thickened that malignant disease is simulated. Microscopic ex- amination of tissue excised will establish the diagnosis. A rectal fistula discharging through the labium has been mistaken for an abscess of Bartholin's gland. Examination per rectum in such a case reveals brawny swelling, and the opening of the fistula in the bowel may be made out by means of the proctoscope and the probe. Hematoma of the labium makes a more uniform swelling than a cyst or abscess and feels doughy, also the skin is dark in the case of the hematoma and there is a history of injury or of recent parturition. Inguino-labial hernia appears in the upper part of the labium and tends to disappear when the patient lies down. There is an impulse on coughing, and in the case of hydrocele of the canal of Nuck the swelling is also in the upper part of the labium, but it is irreducible. Hydrocele of the Canal of Nuck is treated in the chapter on the diseases of the uterine ligaments. (See Chapter XII., page 213.) LABIAL HERNIA An inguinal hernia not infrequently finds its way into the labium majus and sometimes there is a double hernia of this sort. The hernia descends through the inguina canal and follows the course of the round ligament into the labium; this form of hernia being analogous to scrotal hernia in the male. The hernial sac may con- tain only omentum or it may hold intestine, the uterine tubes, the ovaries, or even the uterus. It is caused by the failure of the canal of Nuck to become obliterated. The patient complains of pains in the region of the hernia, especially on exertion, and is apt to suffer with dyspepsia and constipation. If the hernia is reducible the lump in the vulva disappears when the patient is in the recumbent posture. BENIGN TUMORS OF THE VULVA 413 If the sac contains omentum the swelling is irregular in feel, provided the fat over the tumor is not excessive in amount, thus obscuring the tactile sense. The percussion note is flat and there is no gurgling sound in it when reduced and very little impulse on coughing. If the hernial sac contains intestine the swelling is smooth, regu- lar, and elastic. It is increased in size and becomes more tense on coughing or straining, and if reducible disappears or becomes smaller when the patient lies down. As the hernia goes back into the abdominal cavity a gurgling sound is heard. The tumor of the labium is tympantic to percussion and an impulse is transmitted to it when the patient coughs. Should an ovary be in the hernial sac pressure will cause pain similar to the pain experienced when the normal ovary is pressed between the fingers in a bimanual examination. If the uterus is in the sac bimanual examination of the pelvis will reveal the absence of the uterus from its usual situation. Differential Diagnosis. — Hernia into the labium must be differ- entiated from hydrocele of the canal of Nuck, from a tumor of the labium, or a cyst of Bartholin's gland. From the first it is distin- guished by the fact that it is tympanitic, has an impulse on coughing, may have an irregular contour, is reducible, and has gurgling on reduction. Hydrocele is irreducible, is of smooth outline, has no impulse, and is flat to percussion. A solid tumor of the labium is generally of hard consistency; it projects from the surface, has no impulse on coughing and no gurgling. A cyst of Bartholin's gland is globular, has no impulse, is flat to percussion, and is situ- ated in the lower part of the labium, whereas a hernia is oval, has an impulse, may be tympanitic, and is in the upper part of the labium. BENIGN TUMORS OF THE VULVA These are fibroma, myoma, myxoma, neuroma, angioma, lipoma, and cysts. They are rare. Most of them affect the labia majora. J. Bondi has found three sorts of cysts of the labia minora, of which the mucous cysts are the most frequent. He thinks they represent remains of the Wolffian bodies. They are situated in the upper part of the labium. Lipoma may grow from the fatty tissue of the 414 DISEASES OF THE VULVA mons veneris or the labia majora, or even from the nymphae, and may attain considerable size. The diagnosis of benign tumors can not be made exactly, short of removal and microscopic ex- amination of the tissues of the tumor. Slow growth is the rule, and the only symptoms are interference with coitus and the discomfort attending the presence of the growth. MALIGNANT TUMORS OF THE VULVA These are cancer and sarcoma. Cancer. — Primary cancer of the vulva is rare. It is a disease of advanced life, usually occurring between the ages of forty-five and sixty. Its most frequent point of origin is the groove between the nympha and the labium majus, but it may develop from the prepuce of the clitoris or any of the structures of the vulva. The cancer appears in one of three forms, as a circumscribed elevation, as a deep ulceration with infiltrated margins, or as a diffuse infil- tration. The circumscribed growth is a firm tumor rising from the surface of the vulva and more or less movable on the under- lying, infiltrated tissues. If the cancer has broken down it is a friable lobulated or warty mass, showing points of ulceration. The surface is granular, furrowed, and bright red in color, and the base is indurated. The carcinoma may invade the deeper tissues from the beginning, not forming a circumscribed growth on the surface. In this case the tissues become of a brawny hardness and are thickened over an area of considerable extent. This sort of growth may progress very slowly, and ulceration may not appear for several years. The tendency of the disease is to involve the struc- tures of one side of the vulva and then to extend to the opposite side, perhaps by inoculation. The lymphatic glands of the groin are involved early, and the individual glands are to be distin- guished as separate, hard lumps. Cancer of Bartholin's gland occurs as a round, indurated tumor, often as large as a hen's egg, in the lower portion of the labium majus. The tumor is generally very vascular, and large vessels can be made out in the overlying skin. Cancer of the vulva is of the type of squamous-celled carcinoma, and cancer " pearls," due to horny degeneration of the centers of MALIGNANT TUMORS OF THE VULVA 415 the epithelial nests, are abundant. Like cancer in other situations in the genital organs, this form of cancer has no symptoms which are peculiar to itself. Pain is a late symptom after the disease has extended and involved the larger nerve trunks. Ulceration causes local tenderness and a discharge. Differential Diagnosis of Cancer. — In the early stages of cancer the following diseases must be excluded : tuberculosis, condylomata lata and acuminata, chancre, chancroids, and urethral caruncle. Tuberculosis occurs in younger women, i.e., between twenty and forty years of age, and is of slower growth; the nodules are mul- tiple and soft, the induration of the base being absent; tubercles may often be seen in the cheesy degenerated areas; and the in- guinal glands are not involved. The microscope will